Provider Demographics
NPI:1679620306
Name:SPENCER, SCOTT JASON (DC)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:JASON
Last Name:SPENCER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 W RANDOLPH ST
Mailing Address - Street 2:1205
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60606-1867
Mailing Address - Country:US
Mailing Address - Phone:312-265-6908
Mailing Address - Fax:312-264-0347
Practice Address - Street 1:205 W RANDOLPH ST
Practice Address - Street 2:1205
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60606-1867
Practice Address - Country:US
Practice Address - Phone:312-265-6908
Practice Address - Fax:312-264-0347
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038009369111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL7626403OtherAETNA
IL01629928OtherBLUE CROSS BLUE SHIELD
IL01629928OtherBLUE CROSS BLUE SHIELD